The Digestive System|
(gallstone formation) is the commonest disorder of the biliary tree and it is
unusual for the gallbladder to be diseased in the absence of gallstones. The
condition affects about 20% of the population above 40 years of age.
Gallstones are conveniently classified into cholesterol
(made from cholesterol) or pigment
stones (made from bilirubin with a variable degree of calcification).
Cholesterol stones are the commonest
type of gallstones encountered in developed countries (75%).
Causes for gallstone formation:
cholesterol gallstones occur when bile is supersaturated with cholesterol
so it can crystallise, which can occur in different settings. Cholesterol is
water insoluble and becomes water soluble by aggregation with bile salts and
phospholipids such as lecithins, which are also found in bile. Risk factors
for cholesterol stones are:
increased age, female sex, increased parity, hormone replacement therapy,
obesity, gastric surgery. The role of dietary cholesterol and
hypercholesterolaemia is not certain, while high fat/low fibre diet and
diabetes increase the risk. These stones are whitish/yellow, mainly round and
greasy on the surface.
pigment gallstones are formed when there is excess of unconjugated or conjugated
bilirubin. Probably many factors can contribute to this situation such as
infection in the biliary tree (through bacterial production of enzymes which
can deconjugate bilirubin thus initiating precipitation and stone formation),
haemolytic anaemia (increased production of bilirubin) and alcoholic cirrhosis
(impaired conjugation of bilirubin). These stones are black, irregular,
faceted or round, hard, almost like river pebbles, since they contain a
substantial amount of calcium salts.
Acute cholecystitis (inflammation of the gallbladder) is almost always associated with obstruction of the gallbladder neck or cystic duct by a gallstone. Reactive chemical inflammation of the gallbladder mucosa due to changes in chemical composition of bile follows eventually becoming bacterial in type (bacteria usually belong to normal gut flora). However, the exact pathogenesis of this transition is still not clear. Some patients have a chronic form of cholecystitis characterised by thick walled, fibrotic and contracted gallbladder, and presence of biliary sludge/stones in the lumen.
Clinical features: < BACK TO TOP >
of gallstones are asymptomatic and remain so; only 20% sufferers develop
clinical evidence of the disease.
eventually may present either as recurrent
biliary pain caused by transient cystic duct obstruction or cholecystitis due to persistent cystic duct obstruction that
pain is located in the epigastrium or right upper abdominal quadrant, and
radiates to the back to the interscapular region or the tip of the right
pain characteristically occurs after a fatty meal, progressively increasing to
a plateau; it is sustained for about an hour and then subsiding gradually;
overall duration of the pain is up to several hours.
and vomiting often accompany the pain.
cholecystitis, together with more persistent pain (over 24 hours), usually
presents with restlessness, pallor, sweating, nausea, vomiting, fever; fever
is the most important distinguishing feature between uncomplicated biliary
pain and cholecystitis.
in the right upper quadrant is usually noted, and jaundice can occur sometimes
probably caused by oedema and obstruction of the common bile duct.
typical episode of acute cholecystitis improves in 2-3 days and disappears
within 1 week; the most feared outcome is rupture of the gallbladder with
spilling of purulent exudate (pus) into the abdominal cavity, leading to
Differentiation between uncomplicated biliary pain and acute cholecystitis is often difficult on clinical ground.
Diagnosis: < BACK TO TOP >
radiographs of the abdomen may show gallstones if they are radiopaque
(cholesterol stones are not visible but bilirubin ones usually are due to
their greater calcium component).
detects gallstones over 4mm in diameter and may show gallbladder thickening
due to cholecystitis (oedema of the wall in acute and scarring in chronic
and cholescintigraphy show all types of gallstones as filling defects, but in
cholecystitis the gallbladder usually can not be visualised due to cystic
function tests are non-specific (variable increase in hepatic transaminases
and alkaline phosphatase).
Acute cholecystitis can be accompanied by leukocytosis and raised ESR.
Management < BACK TO TOP >
gallstones found incidentally are not usually treated.
gallstones are best treated surgically by means of cholecystectomy (removal
of the gallbladder), preferably through a laparoscopic approach.
Cholecystectomy relieves pain but for unknown reasons 50% of patients
continue experiencing various digestive symptoms.
dissolution of cholesterol gallstones that are not calcified can be attempted
using drugs based on bile acids such as ursodeoxycholic [Ursofalk] which
increases the solubility of cholesterol. This is usually carried out in
patients who decline surgery or when a surgery is associated with significant
shock wave lithotripsy (ESWL) is a technique of gallstones fragmentation
using shock waves (powerful vibrations) applied under water or on special
table with a water-filled cushion. Fragments formed in this way can pass
naturally through the biliary system or may dissolve and disappear
spontaneously or on treatment.
of acute cholecystitis consists of bed rest, relief of pain, antibiotics and
maintenance of fluid balance. Surgical treatment is necessary
(cholecystectomy by either laparotomy or laparoscopy) but it is usually done
later (elective surgery).
In some centres the surgery is attempted in acute episode of cholecystitis avoiding two hospitalisations and reducing costs, but such surgery can be more risky than the postponed one (e.g., rupture of acutely inflamed gallbladder with secondary peritonitis).
Prognosis < BACK TO TOP >
Nutrition < BACK TO TOP >
Nutrition that alleviate or prevent Gallstones :-
Herbs < BACK TO TOP >
Herbs that alleviate or prevent Gallstones :-
(source : -)
12 August 20096December 2005
speaker Mr NgThian Watt the Principal Trainer from
Napoleon Hill Associates MalaysiaDetails